CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

Access to emergency services

Scope:

• The scope of this Impact Analysis is limited to 50% of the participants enrolled during the audit review period who were not included in the provision of
services sample selection.
• The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.

Instructions:

• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Read each question carefully before responding.
• Respond to the questions in the participant impact tab.
• The review timeframe is the audit review period stated above. Errors noted prior to the audit review period should not be included.
• After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the changes in the RCA tab.

Impact Analysis Due Date:

Date Identified
(MM/DD/YY)
(Completed By The CMS
Audit Lead)

Brief Description Of Issue
(Completed By The CMS Audit Lead)

Condition Language
(Completed By The CMS Audit Lead)

Pending OMB Approval (0938-New)

Detailed Description of the Issue
(Explain what happened)
(Remaining fields to be Completed by PACE Organization)

Root Cause Analysis for the Issue
(Explain why it happened)

Methodology - Describe the process that
was undertaken to determine the # of
individuals (e.g. participants) impacted

# of Individuals
Impacted

Action Taken to Resolve System/
Operational Issues

Pending OMB Approval (0938-New)

Date System/ Operational Remediation Date System/ Operational Remediation
Initiated
Completed (MM/DD/YY)
(MM/DD/YY)

Actions Taken to Resolve Negatively Impacted Individuals Date Individual Outreach and Remediation
Including Outreach Description and Status
Initiated
(MM/DD/YY)

Date Individual Outreach and
Remediation Completed
(MM/DD/YY)

Pending OMB Approval (0938-New)

General Information: This information is to be completed for all Impact Analyses
Participant First Name
Participant Last Name
Participant ID

Date of Enrollment

Date of Disenrollment

MM/DD/YYYY

MM/DD/YYYY

Reason for Disenrollment

Emergency Notification Information: This is to be completed for all selected participants.
During the audit review period, did the participant
Did the participant contact the If the participant contacted the PO before
utilize emergency services or request to utilize
PO before going to the ER?
going to the ER please enter the date and
emergency services (this includes requests from
time of the initial contact.
(Yes/No)
caregivers)?
MM/DD/YYYY, HH:MM AM/PM
(Yes/No)
Enter NA if the participant did not contact
If the answer to this question is no the PO may enter
the PO before utilizing emergency services.
NA in all remaining columns.

Please briefly describe the concerns and/or symptoms reported by the
participant and/or caregiver.
Enter NA if the participant did not contact the PO before utilizing emergency
services.

Did staff or contractors from the PO
assess the participant in response to the
participant/caregiver's initial contact?
(Yes/No)
Enter NA if the participant did not
contact the PO before utilizing
emergency services.

Who conducted the assessment of the
participant (PCP, on-call nurse, etc.).

Date of assessment.

MM/DD/YYYY
Enter NA if the participant did not contact
the PO before utilizing emergency services. Enter NA if the participant did not
contact the PO before utilizing
emergency services.

Time of assessment.
HH:MM AM/PM
Enter NA if the participant did not
contact the PO before utilizing
emergency services.

Was the assessment completed prior to the
participant utilizing the ER?
(Yes/No)
Enter NA if the participant did not utilize the
ER or if the participant/caregiver did not
contact the PO before utilizing emergency
services.

Did staff or contractors from the PO:
• Instruct the participant and/or caregiver that prior authorization was needed before going to the
ER or calling 911; or
• Instruct the participant and/or caregiver that approval was needed before going to the ER or
calling 911; or
• Instruct the participant and/or caregiver not to go to the ER or call 911?
(Yes/No)
Enter NA if the participant did not contact the PO before utilizing emergency services.

ER Utilization: These questions only apply to participants who utilized ER services. Enter NA if the participant did not utilize emergency services.
Date/ Time the participant went to the ER.
Did emergency room records indicate that the
If emergency room records indicated that the participant experienced an emergent situation, please
participant was experiencing an emergent situation?
describe the situation.
MM/DD/YYYY, HH:MM
(Yes/No)
Enter NA if the participant did not utilize emergency services.
Enter NA if the participant did not utilize emergency
Enter NA if the participant did not utilize emergency
This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO.
services.
services.
This question applies to all ER visits regardless of
whether the participant/caregiver contacted the PO.

If the participant was evaluated/treated in an ER, what was the
final ER diagnosis.

Was the participant admitted to the hospital or
held for observation?

This question applies to all ER visits regardless of whether the
participant/caregiver contacted the PO.

(Yes/No)

Enter NA if the participant did not utilize emergency services.

Enter NA if the participant did not utilize
emergency services.
This question applies to all ER visits regardless of
whether the participant/caregiver contacted the
PO.

Billing Information: If requested, these questions must be completed for all selected participants.
Was the participant held responsible for any of the cost of the ER
If yes, how much?
visit?
This question applies to all ER visits regardless of whether the
(Yes/No)
participant/caregiver contacted the PO.
This question applies to all ER visits regardless of whether the
participant/caregiver contacted the PO.

Enter NA if the PO covered 100% of the cost of the ER visit.

Additional Information: This is to be completed for all participants during the Impact Analysis review period.
Did the participant experience any negative outcomes after being instructed:
If yes, describe the negative outcomes.
• That prior authorization was needed before to going to the ER or calling 911; or
• That approval was needed before to going to the ER or calling 911; or
• Not to go to the ER or call 911?
(Yes/No)
Enter NA if none of the above are applicable.

Enter NA if the participant did not experience any negative outcomes.

Optional: Please note, you do not have to complete this column.
If there are any mitigating factors that you would like CMS to consider related to a
specific participant, please enter the information in this column.